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Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications

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Abstract

Purpose

The exponential increase in total hip arthroplasty (THA) has led to acute and chronic surgery-related complications. Common chronic and local complications are represented by hip ossification (HO). The aim of our study was to assess the clinical and radiological correlates of patients undergoing surgical removal of heterotopic ossifications after THA and the possible association between HO and prosthetic joint infection.

Methods

Data of 26 patients who underwent surgical removal of periprosthetic calcifications after THA from 2000 to 2022 were analyzed and compared with characteristics of 156 subjects without HO.

Results

The preoperative radiographs of patients showed a high-grade Brooker, 3 or 4, later reduced to 1 or 2 in the postoperative radiographs. Ten (38.5%) patients underwent radiotherapy prophylaxis, administered as a single dose 24 h before surgery. In 19 (73%) patients, pharmacological prophylaxis with indomethacin was added in the 30 postoperative days. Only one patient who underwent radiotherapy had a recurrence, while new ossifications were found in three patients without prophylaxis (11.5%). Intraoperative cultures were performed for suspected periprosthetic infection in 8 study group patients. In logistic regression, the presence of HO was significantly and inversely associated with the ASA score (OR = 0.27, 95% CI = 0.09–0.82; P = 0.021) after adjusting.

Conclusion

Surgical HO removal in symptomatic patients with high-grade disease produces good clinical and radiographic results. Radiotherapy was a good perioperative and preventive strategy for recurrence, also associated with NSAIDs and COX-2 inhibitors.

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Data Availability

Data supporting results of this study are available from the corresponding author upon reasonable request.

References

  1. Learmonth ID, Young C, Rorabeck C (2007) The operation of the century: total hip replacement. The Lancet 370:1508–1519. https://doi.org/10.1016/S0140-6736(07)60457-7

    Article  Google Scholar 

  2. Healy WL, Iorio R, Clair AJ et al (2016) Complications of total hip arthroplasty: standardized list, definitions, and stratification developed by the hip society. Clin Orthop 474:357–364. https://doi.org/10.1007/s11999-015-4341-7

    Article  PubMed  Google Scholar 

  3. Aljurayyan A, Tanzer D, Tanzer M (2016) Acute revision hip arthroplasty: a previously unrecognized risk factor for heterotopic ossification. Eur J Orthop Surg Traumatol 26:183–188. https://doi.org/10.1007/s00590-015-1733-z

    Article  PubMed  Google Scholar 

  4. Ritter MA, Vaughan RB (1977) Ectopic ossification after total hip arthroplasty. Predisposing factors, frequency, and effect on results. J Bone Joint Surg Am 59:345–351

    Article  CAS  PubMed  Google Scholar 

  5. Iorio R, Healy WL (2002) Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg 10:409–416. https://doi.org/10.5435/00124635-200211000-00005

    Article  PubMed  Google Scholar 

  6. Ranganathan K, Loder S, Agarwal S et al (2015) Heterotopic ossification: basic-science principles and clinical correlates. J Bone Joint Surg Am 97:1101–1111. https://doi.org/10.2106/JBJS.N.01056

    Article  PubMed  Google Scholar 

  7. Vasileiadis GI, Amanatullah DF, Crenshaw JR et al (2015) Effect of heterotopic ossification on hip range of motion and clinical outcome. J Arthroplasty 30:461–464. https://doi.org/10.1016/j.arth.2014.09.019

    Article  PubMed  Google Scholar 

  8. Liu JZ, Frisch NB, Barden RM et al (2017) Heterotopic ossification prophylaxis after total hip arthroplasty: randomized trial of 400 vs 700 cGy. J Arthroplasty 32:1328–1334. https://doi.org/10.1016/j.arth.2016.10.030

    Article  PubMed  Google Scholar 

  9. Ohlmeier M, Krenn V, Thiesen DM et al (2019) Heterotopic ossification in orthopaedic and trauma surgery: a histopathological ossification score. Sci Rep 9:18401. https://doi.org/10.1038/s41598-019-54986-2

    Article  ADS  CAS  PubMed  PubMed Central  Google Scholar 

  10. Hayashi D, Gould ES, Ho C et al (2019) Severity of heterotopic ossification in patients following surgery for hip fracture: a retrospective observational study. BMC Musculoskelet Disord 20:348. https://doi.org/10.1186/s12891-019-2725-7

    Article  PubMed  PubMed Central  Google Scholar 

  11. Balboni TA, Gobezie R, Mamon HJ (2006) Heterotopic ossification: pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol 65:1289–1299. https://doi.org/10.1016/j.ijrobp.2006.03.053

    Article  Google Scholar 

  12. Onsen LT, Ouyang VW, Jimenez AE et al (2021) Simplified biplanar classification for heterotopic ossification is more predictive of patient-reported outcomes than the Brooker classification after anterior total hip arthroplasty. HIP Int 112070002110391. https://doi.org/10.1177/11207000211039173

  13. Mourad WF, Packianathan S, Shourbaji RA et al (2012) The impact of body mass index on heterotopic ossification. Int J Radiat Oncol 82:e831–e836. https://doi.org/10.1016/j.ijrobp.2011.11.033

    Article  Google Scholar 

  14. Rosteius T, Rausch V, Pätzholz S et al (2019) Incidence and risk factors for heterotopic ossification following periprosthetic joint infection of the hip. Arch Orthop Trauma Surg 139:1307–1314. https://doi.org/10.1007/s00402-019-03215-6

    Article  PubMed  Google Scholar 

  15. Manrique J, Alijanipour P, Heller S et al (2018) Increased risk of heterotopic ossification following revision hip arthroplasty for periprosthetic joint infection. Arch Bone Jt Surg 6:486–491

    PubMed  PubMed Central  Google Scholar 

  16. Higo T, Mawatari M, Shigematsu M, Hotokebuchi T (2006) The incidence of heterotopic ossification after cementless total hip arthroplasty. J Arthroplasty 21:852–856. https://doi.org/10.1016/j.arth.2005.10.016

    Article  PubMed  Google Scholar 

  17. Eggli S, Woo A (2001) Risk factors for heterotopic ossification in total hip arthroplasty. Arch Orthop Trauma Surg 121:531–535. https://doi.org/10.1007/s004020100287

    Article  CAS  PubMed  Google Scholar 

  18. Matsen Ko L, Parvizi J (2016) Diagnosis of periprosthetic infection. Orthop Clin North Am 47:1–9. https://doi.org/10.1016/j.ocl.2015.08.003

    Article  PubMed  Google Scholar 

  19. Veltman ES, Moojen DJF, van Ogtrop ML, Poolman RW (2019) Two-stage revision arthroplasty for coagulase-negative staphylococcal periprosthetic joint infection of the hip and knee. World J Orthop 10:348–355. https://doi.org/10.5312/wjo.v10.i10.348

    Article  PubMed  PubMed Central  Google Scholar 

  20. Romanò CL, Khawashki HA, Benzakour T et al (2019) The W.A.I.O.T. definition of high-grade and low-grade peri-prosthetic joint infection. J Clin Med 8:650. https://doi.org/10.3390/jcm8050650

  21. Yu B-Z, Li R, Fu J et al (2021) Leukocyte esterase test and alpha-defensin test have similar accuracy for the diagnosis of periprosthetic joint infection. Int Orthop 45:1677–1682. https://doi.org/10.1007/s00264-020-04903-4

    Article  PubMed  Google Scholar 

  22. Gemmel F, Van den Wyngaert H, Love C et al (2012) Prosthetic joint infections: radionuclide state-of-the-art imaging. Eur J Nucl Med Mol Imaging 39:892–909. https://doi.org/10.1007/s00259-012-2062-7

    Article  CAS  PubMed  Google Scholar 

  23. Papalia R, Vespasiani-Gentilucci U, Longo UG et al (2019) Advances in management of periprosthetic joint infections: an historical prospective study. Eur Rev Med Pharmacol Sci 23:129–138. https://doi.org/10.26355/eurrev_201904_17482

  24. Zhu X-T, Chen L, Lin J-H (2018) Selective COX-2 inhibitor versus non-selective COX-2 inhibitor for the prevention of heterotopic ossification after total hip arthroplasty: a meta-analysis. Medicine (Baltimore) 97:e11649. https://doi.org/10.1097/MD.0000000000011649

    Article  CAS  PubMed  Google Scholar 

  25. Rath E, Warschawski Y, Maman E et al (2016) Selective COX-2 inhibitors significantly reduce the occurrence of heterotopic ossification after hip arthroscopic surgery. Am J Sports Med 44:677–681. https://doi.org/10.1177/0363546515618623

    Article  PubMed  Google Scholar 

  26. Knahr K, Salzer M, Eyb R et al (1988) Heterotopic ossification with total hip endoprostheses in various models of thrombosis prophylaxis. J Arthroplasty 3:1–8. https://doi.org/10.1016/S0883-5403(88)80047-0

    Article  CAS  PubMed  Google Scholar 

  27. Nunley RM, Zhu J, Clohisy JC, Barrack RL (2011) Aspirin decreases heterotopic ossification after hip resurfacing. Clin Orthop 469:1614–1620. https://doi.org/10.1007/s11999-011-1846-6

    Article  PubMed  PubMed Central  Google Scholar 

  28. Winkler S, Craiovan B, Wagner F et al (2015) Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany. Arch Orthop Trauma Surg 135:481–489. https://doi.org/10.1007/s00402-015-2174-1

    Article  CAS  PubMed  Google Scholar 

  29. Pakos EE, Ioannidis JPA (2004) Radiotherapy vs. nonsteroidal anti-inflammatory drugs for the prevention of heterotopic ossification after major hip procedures: a meta-analysis of randomized trials. Int J Radiat Oncol 60:888–895. https://doi.org/10.1016/j.ijrobp.2003.11.015

    Article  CAS  Google Scholar 

  30. Healy WL, C.M.Lo T, Covall DJ et al (1990) Single-dose radiation therapy for prevention of heterotopic ossification after total hip arthroplasty. J Arthroplasty 5:369–375. https://doi.org/10.1016/S0883-5403(08)80097-6

  31. Board TN, Karva A, Board RE et al (2007) The prophylaxis and treatment of heterotopic ossification following lower limb arthroplasty. J Bone Joint Surg Br 89-B:434–440. https://doi.org/10.1302/0301-620X.89B4.18845

  32. Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251. https://doi.org/10.1016/0895-4356(94)90129-5

    Article  CAS  PubMed  Google Scholar 

  33. Kaplan FS, Glaser DL, Hebela N, Shore EM (2004) Heterotopic ossification. J Am Acad Orthop Surg 12:116–125. https://doi.org/10.5435/00124635-200403000-00007

    Article  PubMed  Google Scholar 

  34. Wu X-B, Yang M-H, Zhu S-W et al (2014) Surgical resection of severe heterotopic ossification after open reduction and internal fixation of acetabular fractures: a case series of 18 patients. Injury 45:1604–1610. https://doi.org/10.1016/j.injury.2014.05.018

    Article  PubMed  Google Scholar 

  35. Macheras GA, Lepetsos P, Leonidou A et al (2017) Results from the surgical resection of severe heterotopic ossification of the hip: a case series of 26 patients. Eur J Orthop Surg Traumatol 27:1097–1102. https://doi.org/10.1007/s00590-017-1980-2

    Article  PubMed  Google Scholar 

  36. Łęgosz P, Otworowski M, Sibilska A et al (2019) Heterotopic ossification: a challenging complication of total hip arthroplasty: risk factors, diagnosis, prophylaxis, and treatment. BioMed Res Int 2019:1–8. https://doi.org/10.1155/2019/3860142

    Article  CAS  Google Scholar 

  37. Cobb TK, Berry DJ, Wallrichs SL et al (1999) Functional outcome of excision of heterotopic ossification after total hip arthroplasty. Clin Orthop 361:131–139. https://doi.org/10.1097/00003086-199904000-00018

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128, Rome, Italy

    B. Zampogna, A. Laudisio, G. F. Papalia, F. Vorini, A. Zampoli, R. Righini, G. Vadalà & R. Papalia

  2. Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128, Rome, Italy

    B. Zampogna, A. Laudisio, G. F. Papalia, F. Vorini, A. Zampoli, R. Righini, G. Vadalà & R. Papalia

  3. Research Unit of Geriatrics, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy

    A. Laudisio

  4. Operative Research Unit of Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy

    M. Fiore & S. Ramella

  5. Research Unit of Radiation Oncology, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy

    M. Fiore & S. Ramella

  6. Operative Research Unit of Clinical Laboratory Science, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128, Rome, Italy

    S. Angeletti

  7. Research Unit of Clinical Laboratory Science, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21 - 00128, Rome, Italy

    S. Angeletti

Authors
  1. B. Zampogna
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  11. R. Papalia
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Contributions

All authors contributed to the study conception and design. All authors read and approved the final manuscript.

Corresponding author

Correspondence to A. Laudisio.

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This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Fondazione Policlinico Universitario Campus Bio-Medico.

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Zampogna, B., Laudisio, A., Papalia, G.F. et al. Heterotopic hip ossification resection: monocentric experiences of associated factors, outcomes, and complications. International Orthopaedics (SICOT) 48, 699–704 (2024). https://doi.org/10.1007/s00264-023-05993-6

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